DESCRIPTION (Applicant's abstract): High rates of depression among the elderly with physical illness and impaired functioning are well documented. Efficacious treatments for depression among the elderly are available, but all too often depressed elderly are either not diagnosed or not treated properly. Elderly patients have been consistently found to underutilize formal mental health services. On the other hand, the elderly are heavy utilizers of general health or primary care services. The Multi-faceted Home Care Depression Program (MHCDP) is a fully integrated, stepped care, collaborative, multi-modal home care model designed to influence the process of home care, the home care provided by physicians and nurses, and patient self-management. It aims to improve the detection and treatment of major depressive disorder (MD} and dysthymia. A controlled, block-randomized clinical trial is proposed to test the effectiveness, acceptability, feasibility, and cost of the MHCDP among 600 enrolled subjects aged 65 years and older who are receiving services in a large urban/rural home care program (SunPlus). The direct cost of detection and treatment under MHCDP is covered through existing reimbursement mechanisms and MHCDP is fully integrated within standard home care practices. Key components of the MHCDP are: 1) a phased baseline detection strategy which includes a depression symptom inventory (SCL-90 Depression) and a structured diagnostic assessment procedure (PRIME-MD PHQ-9) that is brief and will be implemented during the existing standard admitting RN evaluation conducted (during a 2-hour home visit) on all patients referred for home care services; 2) a stepped care treatment algorithm that includes patient choice of medication or psychosocial treatment; and 3) specific quality of care enhancements that are fully integrated within existing standard home care practice. These include training existing psychiatric team nurses and social workers in structured Problem-Solving Treatment, informational materials for referring primary care physicians, nurse and social worker training, home care management services to monitor and facilitate depression treatment and to address barriers to care, patient and family/caregiver education, and follow up provided by psychiatric nurses and social workers. Major Hypotheses and Research Questions: (1) MHCDP intervention will result in greater reduction of depressive symptoms vs. usual care; (2) MHCDP will result in greater frequency of primary care physician prescription for drug or psychosocial treatment vs. usual care; and (3) MHCDP will increase patient acceptance of and adherence to treatment and satisfaction with care vs. usual care. In addition, we will conduct: (1) comparisons of functional status, quality of life, suicidal ideation, and service utilization between intervention vs. usual care patients; and (2) cost-benefit comparisons of estimates of direct costs of the intervention and usual care arms.